Extremities Feature

The Latest in Orthopedic Rehabilitation

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, January 9th, 2017

A new specialty update was published in the November edition of The Journal of Bone and Joint Surgery. This work, performed at Vanderbilt University, examined evidence from studies published from March 2015 to February 2016 in a variety of journals. The researchers involved were Nitin Jain, M.D., M.S.P.H., John Kuhn, M.D., William Murrell, M.D., and Kristin Archer, Ph.D., D.P.T.

Dr. Archer commented to OTW, “Some of the most important findings of our review include the increased use of novel rehabilitation strategies to reduce pain and increase function in patients with musculoskeletal injuries and disorders, such as whole-body vibration, psychosocial based programs, and cannabinoids.”

“Non-traditional delivery approaches such as telerehabilitation and telephone demonstrate similar or better outcomes than in-person clinic visits. Also, the literature does not support early imaging and early physical therapy for patients with acute low back pain.”

“Larger studies are needed to understand the differences in patient-reported outcomes and cost between operative treatment and non-surgical management for patients with upper extremity disorders.”

Asked about how orthopedic surgeons could increase their understanding of rehab, Dr. Archer noted, “It would be good to have an increased understanding of the impact of patient psychosocial factors on rehabilitation outcomes and health-care resource utilization. A psychosocial risk assessment and a targeted rehabilitation approach has the potential to help those individuals at high-risk for poor outcomes.”

“Our research lab continues to develop and test rehabilitation programs that incorporate self-management, cognitive-behavioral, and mind-body strategies to reduce pain and improve function in patients with acute and chronic musculoskeletal pain. We are particularly interested in understanding the differences in outcomes and cost between telerehabilitation and traditional, in-person clinic programs.”

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Obese Benefit Equally From Joint Replacement

Biloine W. Young • Fri, October 6th, 2017

There is good news for obese patients who are contemplating a joint replacement.

Contrary to previous research, a new study suggests that the obese may not need to lose weight prior to their surgery. The study found that obese patients experience the same pain relief and improved function six months post-surgery as do normal weight patients.

“Our data shows it’s not necessary to ask patients to lose weight prior to surgery,” said Wenjun Li, Ph.D., associate professor of medicine and lead author on of the study, published in the Journal of Bone and Joint Surgery.

He added, “It’s challenging for a patient who is severely overweight and suffering in pain to exercise—often they just can’t do it. Our evidence showed that severe morbidly obese patients can benefit almost equally as normal weight patients in pain relief and gains in physical function.”

For their study the researchers collected preoperative and six-month postoperative data on the function, joint pain and body mass index (BMI) of a sample of 2,040 patients who had undergone total hip replacement and 2,964 who had undergone total knee replacement. The surgeries took place from May 2011 to March 2013. They found that a greater obesity level was associated with worse pain at baseline but greater postoperative pain relief. The average postoperative pain scores at six months were similar across the various BMI levels.

This outcome surprised the researchers, Li said. “Past analysis had shown that obesity was associated with outcomes to some degree. But here we see the magnitude is so small it won’t make much difference, and severely obese patients can benefit a lot from the surgery.”

Shu-Fen Sun, M.D. is with the Department of Physical Medicine and Rehabilitation at Kaohsiung Veterans General Hospital in Taiwan. A co-author on the study, Dr. Sun commented to OTW, “To date, there is no well-controlled trial comparing a single injection of hyaluronan (HA) for knee OA. This study compared the efficacy and safety of a single intra-articular injection of a novel crosslinked HA (HYAJOINT Plus) with a single injection of Synvisc-One in patients with knee OA.”

Dr. Sun told OTW, “Both a single injection of HYAJOINT Plus and Synvisc-One are safe and effective for 6 months in patients with knee OA. HYAJOINT Plus is superior to Synvisc-One in VAS pain reduction at 1, 3 and 6 months, with similar safety.”

Zyga: 12-Month Results on SI Joint Fusion

Elizabeth Hofheinz, M.P.H., M.Ed. • Thu, December 22nd, 2016

Zyga Technology, Inc. has some positive results to announce…their 12-month clinical and radiographic results have been published in The Open Orthopaedics Journal. The study evaluated long-term fusion and pain reduction in patients receiving SImmetry Sacroiliac Joint Fusion.

"Minimally invasive SI joint fusion procedures have demonstrated significant reduction in pain and disability, but it is important that these procedures create a bony fusion to give patients the best opportunity for long-term relief, " said Richard A Kube M.D., study author and orthopedic spine surgeon at Prairie Spine and Pain Institute in Peoria, Illinois, in the December 14, 2016. "This technique minimizes the invasiveness of the procedure without compromising any of the orthopedic principles that provide the foundation for a successful fusion."

As indicated in the news release, “This single-center study enrolled 18 patients who underwent a total of 20 minimally invasive SI joint fusion procedures with decortication and bone grafting. Pain and disability scores were collected pre-surgery and at 6 weeks, 3 months, 6 months, 9 months and 12 months post-surgery. A CT scan was also performed at 12-month follow-up. At 12 months, fusion was reported in 88% of patients, and back pain decreased from 81.7 to 44.1 (p<0.001) on average. Freedom from device- or procedure-related adverse events through 12 months was 100%.”

"Zyga is proud to support Dr. Kube, a leader in SI joint fusion, and other ongoing clinical research to demonstrate the importance and efficacy of sacroiliac joint fusion, " said company President and CEO Jim Bullock. "This study will be closely succeeded by several other publications, including early results of a prospective, multi-center study evaluating pain reduction and long-term, radiographic fusion."

Dr. Kube told OTW, “I was fascinated to watch our diagnostic protocols be validated by the clinical success we saw in the patients, as well as radiological evidence that the procedure achieved what it was meant to do: decorticate and fuse the joint. It is always rewarding to see the clinical results match the benchtop hypothesis.”

“All patients outside of major multi-trauma patients who were candidates were included in the study. If I had selected for patients with truly isolated SIJ disease or excluded workers comp and personal injury patients, the clinical results would have been even better.

Waiting Too Long for TJR is a Bad Idea

Biloine W. Young • Thu, June 19th, 2014

Is there an optimum time—a window of opportunity—for a patient to get a hip or knee joint replaced? Data from a joint replacement monitoring program and database at UMass Medical School says “yes” and that waiting too long will reduce the benefits of surgery.

“Don’t wait until you can’t walk or take the pain any longer, ” said David Ayers, M.D., the Arthur M. Pappas Chair in Orthopedics, professor of orthopedics and physical rehabilitation and director of the Musculoskeletal Center of Excellence. “That’s what we hear a lot from patients and doctors—to wait until you can’t take it anymore. But the data is telling us that for typical patients, there’s only a fixed amount of improvement you can get from surgery. So if you wait too long, you don’t get the full value.”

Ayers said that this is not about having surgery too early, either. Instead he says that doctors now have objective, data-driven tools that can help patients decide, together with their surgeons, where they are with pain and function and when to have surgery.

The nationally-recognized physical composite score for an individual with no joint pain or functional difficulty is 50. The new data, based on a study of 17, 000 patients, reveals that typical patient scores improve an average of 12 points after total joint replacement (TJR) surgery. Because patients on average experience the same change in functional improvement after surgery, a typical patient who waits until his function is extremely impaired will not achieve the same degree of post-operative function as will a typical patient who chooses surgery at the ideal time.

“What we’re seeing is that the average person who chooses total joint replacement has an average pre-total joint replacement function score of 32, ” said Patricia Franklin, M.D., professor of orthopedics and physical rehabilitations. “On average, TJR patients can achieve scores of 44 or greater and approach the function of non-arthritic patients after surgery. But, 20% of patients who wait until their score is 25 or lower generally don’t get the full 12 points of improvement. In fact, 40% of those who wait this long only achieve post-surgery function at the arthritis level of 32.

New Study Supports Exparel Cost Effectiveness

Biloine W. Young • Wed, January 24th, 2018

In an article by Allison Inserro, published on AJMC.com, “Patients having total knee arthroplasty (TKA) who were treated with liposomal bupivacaine were discharged to their homes sooner and had a significantly shorter hospital stay compared with patients who did not receive that drug during surgery, according to a recently published study looking at the value and cost effectiveness of the drug.”

“Liposomal bupivacaine is sold under the name Exparel. Exparel is delivered through a proprietary foam-based delivery system and costs about $300 per dose. The price of generic bupivacaine is about $3 a dose. The FDA approved Exparel in 2011 for a single-dose infiltration into the surgical site to produce postsurgical analgesia.”

The FDA is presently “reviewing a supplemental new drug application to include administration of Exparel via a nerve block for prolonged regional analgesia.”

“Currently, there are no well-defined guidelines for the best pain management protocol in patients undergoing TKA”, the authors wrote. Traditional methods of management include the use of opioids, patient-controlled analgesia (PCA) and peripheral nerve blocks.”

“The authors hypothesized that a decrease in complications with at least equivalent pain control would lead to improved cost-effectiveness.”

“The study cited some of the side effects of other methods of pain control.

Peripheral nerve blocks have been associated with an increased risk of falls, nerve injury, and temporary loss of motor function, which can delay rehabilitation.

Side effects of opioids include respiratory, hemodynamic, urinary, and gastrointestinal disturbances”

“He also explained that decisions about cost-effectiveness need to be based on the entire cost of an episode.”

“If you have a fall in the hospital because of a femoral nerve block, or you give a patient a narcotic and they get dizzy or nauseous and vomit and their length of stay is extended, or they get too sick from the narcotics and they don’t get good pain relief … and can’t participate in their rehabilitation, they stay in the hospital longer and they even have to go to a rehab.”

Iorio said, “While $300 for 1 drug may seem expensive, an extra day in the hospital might cost close to $6,000, a stay in a rehab center might cost $5,000 to $10,000, and a fall with a fracture after a joint replacement might cost $50,000 to $100,000.”

During the study, between September 2013 and September 2015, the institution where the study was conducted, NYU Langone, began changing how they manage pain after TKA to increase patient satisfaction and also to reduce the amount of narcotics.